When a fictional patient had died
I worried, I paced, and I sighed.
The little white spheroids
Were pills that were steroids
The adrenals had shriveled inside.
Flash back to 1979, when, fresh out of medical school, I was studying for the Boards.
Back then there were no computer based learning programs; an “interactive” program involved using a disclosing highlighter on pulp paper. The name of the book was Clinical Simulations; it gave a clinical scenario, and a series of decision choices. At each decision point I would use the supplied highlighter and printed information would appear where blank space had been, directing me to turn to a new page.
The hypothetical patient, a fifty-four year white female with rheumatoid arthritis, took some “white pills” she got in Mexico for her joint pains, but she came in with right lower quadrant pain suggestive of appendicitis. I asked for more information and found out she smoked, she drank, and worked as a highly paid executive. Labs came through that looked OK, and I continued leafing through the book. I picked the page that let me order IV fluids and send the patient to surgery. As I ran the felt tip yellow marker across the page I read Your patient dies on the operating table. I dropped the marker and the book in shock.
At the time I had little clinical experience and no clinical confidence. A week later I discussed the case with my father, a cardiologist. He didn’t seem at all surprised. He talked about steroid dependency and the need for steroid support when people get sick.
Fast forward to yesterday.
Friday afternoons are always chaotic in doctors’ offices. People getting sick try to get in before the weekend, and I don’t blame them. But people who work in the office also would like to have a long weekend, and frequently the place runs short-staffed. For a long time I have tried to maintain a policy of not scheduling any appointments for Friday afternoon before the switchboard opens on Friday morning. Especially with a crowded schedule, I’ve tried to keep slots open for established patients, and not take new patients on Fridays. As a short timer, with weeks left in my tenure, I shouldn’t get any of the new patients.
Especially not on Friday afternoon.
Yesterday I walked cheerfully into the exam room to greet a new patient, and a relative, for the first time. The two together were a family fragment, a piece away from the context. The problem was cough.
In short order I’d found out about the colon cancer and the ileostomy as well. The patient confirmed status as ex-smoker, and I ordered a chest x-ray. The films showed the battlefield where lung tissue had fought a losing battle against smoke for a very long time.
“Your chest x-ray looks very bad,” I said. “Have you ever been told you have emphysema?”
The patient said yes. I started writing orders for antibiotics and steroids, at the same time I reviewed the medication list. I stopped in mid-prescription. “Why do you take Florinef?” I asked.
One adrenal gland wasn’t functioning when the other one was removed because of a benign tumor.
I clicked on the Vital Signs section and found a blood pressure of 60/40. “Are you feeling OK?” I asked.
The patient felt light-headed and dizzy.
I vividly remembered the yellow highlighter on the grey paper and the words Your patient dies on the operating table. I opened the door and asked my nurse to call the ambulance, and I turned back to the patient and relative. “Your adrenal glands,” I said, “Make steroids like cortisone.” They already knew that. “When you get sick,” I continued, “you have to have more steroids to keep your blood pressure up. If you don’t have adrenal glands to make more steroids your blood pressure can go so low you can die. And right now your blood pressure is dangerously low.”
(President Kennedy had Addison’s disease, where the adrenal glands fail slowly, and by the time he died he had no cortisone of his own manufacture. Back then treatment included injections of testosterone, which puts the Cuban Missile Crisis into a different perspective.)
The nurse came in to ask about what to tell the ambulance. I asked, “What injectable steroids do we have here?”
“Depomedrol and Kenalog,” she said.
“As soon as you can, give forty of Kenalog IM,” I said. “Please.”
I took out my cell phone and called Mercy’s ER to connect to a doctor I’ve known for a decade. I explained the situation, essentially an Addisonian crisis. I apologized that the best steroid I could lay my hands on, on a right now basis, was Kenalog, not the best choice but would hopefully keep the patient alive till the ambulance could get her across town. The doc accepted the transfer.
I’ve never had a patient in an Addisonian crisis before.
The patient and relative asked about continuing care after the hospitalization. I told them the briefest version of my upcoming departure. They expressed disappointment.
When the ambulance pulled away I apologized to other patients for my lateness. I was too busy to breathe a sigh of relief.